FRESH Thematic Indicators PDF

Monitoring and
Evaluation Guidance
for School Health Programs
Thematic Indicators
Supporting FRESH
(Focusing Resources on Effective School Health)
June 2013
Contents
Abbreviations and Acronyms 3

Introduction 4
Purpose and Document Use 4
Thematic Indicator 1: Water, Sanitation and Hygiene 5
Thematic Indicator 2: Worms 9
Thematic Indicator 3: Food and Nutrition 12
Thematic Indicator 4: Physical Activity 16
Thematic Indicator 5: Malaria 19
Thematic Indicator 6: Oral Health 22
Thematic Indicator 7: Eye Health 25
Thematic Indicator 8: Ear and Hearing 28
Thematic Indicator 9: Immunization 30
Thematic Indicator 10: Injury Prevention 33
Thematic Indicator 11: HIV and AIDS 36
Thematic Indicator 12: Sexual and Reproductive Health 40
Thematic Indicator 13: Substance Abuse 43
Thematic Indicator 14: Violence in Schools 47
Thematic Indicator 15: Disaster Risk Reduction 50
Cover Photo courtesy of Francis Peel, The Partnership for Child Development.
MONITORING AND EVALUATION GUIDANCE FOR SCHOOL HEALTH PROGRAMS THEMATIC INDICATORS
Abbreviations and Acronyms
AIDS Acquired immune deficiency syndrome

BMI Body Mass Index
DHS Demographic and Health Surveys
EMIS Education Management Information System
FRESH Focusing Resources on Effective School Health
GARP Global AIDS Response Progress
GSHS Global School-Based Student Health Survey
HBSC Health Behavior in School-Aged Children
HIV Human immunodeficiency virus
IATT Inter-Agency Task Team
ITN Insecticide-treated net
KAP Knowledge, Attitudes and Practices
M&E Monitoring and evaluation
MICS Multiple Indicator Cluster Surveys
NCD Non-communicable disease
NCPI National Commitments and Policy Instruments
PCD The Partnership for Child Development
SHPPS School Health Policies and Practices Study
UNAIDS Joint United Nations Programme on HIV/AIDS
UNESCO United Nations Educational, Scientific and Cultural Organization
UNFPA United Nations Population Fund
UNGASS United Nations General Assembly Special Session
UNICEF United Nations Children’s Fund
UNODC United Nations Office on Drugs and Crime
WASH Water, sanitation and hygiene
WHO World Health Organization
MONITORING AND EVALUATION GUIDANCE FOR SCHOOL HEALTH PROGRAMS THEMATIC INDICATORS 3
Introduction
This part of the FRESH (Focusing Resources on Effective School Health) Monitoring
and Evaluation (M&E) Guidance provides a menu of more than 250 school health-
related indicators, drawn largely from existing M&E guidance and arranged by health
topic (or thematic area).
The level to which these thematic indicators have been component which needs to be monitored and evaluated.
tested or are internationally accepted varies widely by For example, a project focused on HIV prevention in
thematic area. Each thematic indicator page includes a schools can select Thematic Indicator 11: HIV and AIDS
short introduction to the health topic, including a or an education project with a deworming and
rationale for addressing this health issue in schools and micronutrient supplementation component can select
some of the recommended strategies. Within each relevant thematic indicators covering deworming
thematic area, a list of indicators organized by the four (Thematic Indicator 2: Worms) and micronutrients
FRESH pillars (equitable school health policies; safe (Thematic Indicator 3: Food and Nutrition).
learning environment; skills-based health education; and
The thematic indicators in this document are
school-based health and nutrition services) and
suggestions from which countries can choose. These
outcomes (learning; behavioral; and impact) is provided
thematic indicators are not prescriptive and some of
as well as reference to the data collection method and
them may change over time as they get further
where to find more information.
developed and refined. The selection of thematic
indicators should be based on the purpose for which the
Purpose and Document Use
survey is being conducted, for example, for program
M&E, or program planning, and whether the thematic
The purpose of this document is to provide a menu of
indicators are already being collected as part of regular
thematic indicators to support the selection of M&E Core
surveys.
Indicators for school health projects. These projects may
focus on specific health problems or broader health or The following are the thematic indicators and thematic
education projects which have a school health areas (health topics) covered:
Thematic Indicators Thematic Areas (Health Topics)

1 Water, Sanitation and Hygiene (WASH)
2 Worms
3 Food and Nutrition
4 Physical Activity
5 Malaria
6 Oral Health
7 Eye Health
8 Ear and Hearing
9 Immunization
10 Injury Prevention
11 HIV and AIDS
12 Sexual and Reproductive Health
13 Substance Abuse
14 Violence in Schools
15 Disaster Risk Reduction
4 MONITORING AND EVALUATION GUIDANCE FOR SCHOOL HEALTH PROGRAMS THEMATIC INDICATORS
Thematic Indicator 1: Water, Sanitation and Hygiene
Rationale Strategies
Many communities have a high prevalence of diseases Schools can play a key role in reducing WASH-related
related to inadequate water supply, sanitation and issues through construction of water and sanitation
hygiene (particularly lack of hand washing), such as facilities as well as hygiene education. There are many
diarrhea, parasitic worm infections and skin and eye facilities or technologies that can enhance water supply
diseases. Schools, particularly those in rural areas, often and storage, improve water quality, dispose of human
completely lack drinking water and sanitation facilities, feces and solid waste, improve water drainage, and
or have facilities that are inadequate in both quality and increase hand washing opportunities. Hand pumps,
quantity. Communities themselves are at risk when covered water wells, and rainwater harvesting can
schoolchildren are exposed to disease because of improve water supply, while construction of pit latrines
inadequate water supply, sanitation and hygiene at or toilets as well as hand washing facilities using a sink,
school. Families bear the burden of their children’s bowl, or recycled container can improve sanitation and
illness due to these bad conditions at school. hygiene (IRC, 2007).
Conversely, students who have adequate water,
To minimize disease transmission, improvements in
sanitation and hygiene (WASH) conditions at school are
water and sanitation facilities should be accompanied by
more able to integrate hygiene education into their daily
hygiene behavior change interventions as well. Hygiene
lives and can be effective messengers and agents for
interventions can focus on hand washing behavior at
change in their families and the wider community.
key times (before eating and after using the toilet or
Girls and boys, including those with disabilities, are latrine), safe excreta management, and consumption of
likely to be affected in different ways by inadequate clean water (IRC, 2007). Children receiving weekly hand
WASH conditions in schools, and this may contribute to washing promotion and soap had 50% fewer diarrheal
unequal learning opportunities. For example, lack of and respiratory infections than those not receiving the
gender-separated private and secure toilets, latrines and intervention (CDC, n.d.). Inadequate water and sanitation
washing facilities may discourage parents from sending can be addressed through construction of toilets or
girls to school. In addition, lack of adequate facilities for latrines, as well as improved water access at schools.
menstrual hygiene can contribute to girls missing days The hygiene behaviors that children learn at school –
at school; this can even lead to girls dropping out of made possible through a combination of hygiene
education altogether at puberty. Toilets that are education and suitable WASH facilities – are skills that
inaccessible often mean that a disabled child does not they are likely to maintain as adults and pass on to their
eat or drink all day to avoid needing the toilet, leading to own children.
health problems and eventually dropping out of school
altogether.
Water, Sanitation and Hygiene Indicators Table
Indicators Data Collection Data Collection

Frequency Methods
FRESH PILLARS
EQUITABLE SCHOOL HEALTH POLICIES
1. Minimum standards for education on WASH in schools are defined at Every 2 years Document analysis
national-level. and interview with
key informants
2. Percentage of schools that meet their national standards for WASH. Every 2 years School survey
3. Percentage of schools that promote positive hygiene behaviors, Every 2 years School survey
including mandatory correct use and maintenance of facilities
that are systematically promoted among staff and schoolchildren.
4. Percentage of schools that have facilities and resources that enable Every 2 years School survey
staff and schoolchildren to practice behaviors that control disease
transmission in an easy and timely way.
SAFE LEARNING ENVIRONMENT
1. Percentage of schools with a functional water point at or near the Every 2 years School survey
school that provides a sufficient quantity of water for the needs of the
school and is safe for drinking and accessible to children with
disabilities.
2. Percentage of schools with functional toilets and urinals for girls, boys Every 2 years School survey
and teachers that meet national standards and are accessible to
children with disabilities.
3. Percentage of schools with functional hand washing facilities and soap Every 2 years School survey
(or ash) available for girls and boys in the school and where hygiene is
taught.
4. Percentage of schools where solid waste and sludge is regularly Every 2 years School survey
disposed.
ALTERNATIVE INDICATORS (from global surveys)
1a) Percentage of schools with a source of clean drinking water that Every 3 to 5 years Global School Health
students can use. Policies and Practices
Study (SHPPS)
2a) Percentage of schools with separate toilets or latrines for boys to use. Every 3 to 5 years Global SHPPS
2b) Percentage of schools with separate toilets or latrines for girls to use. Every 3 to 5 years Global SHPPS
3a) Percentage of schools with facilities (e.g. sink with water) where Every 3 to 5 years Global SHPPS
students can wash their hands after they use the toilets or latrines or
before they eat.
3b) Percentage of schools where soap is provided for students to Every 3 to 5 years Global SHPPS
use when they wash their hands after they use the toilets or
latrines or before they eat.
4a) Percentage of schools where garbage is removed from school Every 3 to 5 years Global SHPPS
premises every day when school is in session.
SKILLS-BASED HEALTH EDUCATION
1. Percentage of schools that provide hygiene education for Every 2 years School survey /
schoolchildren as part of the school curriculum. Global SHPPS
2. Percentage of students who received hygiene education for Every 2 years School survey
schoolchildren as part of the school curriculum.
3. Percentage of students who have been involved in the design, Every 2 years School survey
development and implementation of a project to promote WASH in
their school.
4. Percentage of teachers who have ever received training in WASH life Every 2 years Training records
skills education.
SCHOOL-BASED HEALTH AND NUTRITION SERVICES
1. Percentage of schools that provide soap for hand washing (i.e. where Every 2 years School survey
enough soap is available for students to wash their hands more than
80% of the time, or 4 out of 5 days per week).
OUTCOMES
LEARNING
1. Percentage of students who know and understand specific facts about Every 2 years School survey
hygiene and menstruation.
2. Percentage of students who have positive attitudes towards specific Every 2 years School survey
behaviors that ensures good personal hygiene.
BEHAVIORAL
1. Percentage of students who demonstrate good hygiene practices and Every 2 years Student survey /
who are encouraging others to do the same. observation
2. Percentage of students who always washed their hands after using Global School-Based
Every 3 to 5 years
Student Health Survey
the toilet or latrine during the past 30 days.
(GSHS).
IMPACT
1. Percentage of school-age children attending school with diarrheal Every 3 to 5 years DHS/MICS or student
disease, 2 weeks prior to the survey. in the case of the survey
Demographic and
Health Surveys
(DHS)/ Multiple
Indicator Cluster
Surveys (MICS)
Every 2 years for a

dedicated survey
2. Percentage of students missing school (5) or more days in a school Every 2 years Student survey
year due to illness or injury.
3. Gender equity: ratio of girls to boys in school attendance (access to Annually Education
education). Management
Information System
(EMIS)
Sources and Further Information
Introduction adapted from:
World Health Organization (WHO). (2009). Water, sanitation and hygiene standards for schools in low-cost settings.
Edited by Adams, J., Bartram, J., Chartier, Y. and Sims, J. Geneva, WHO.
http://www.who.int/water_sanitation_health/publications/wash_standards_school.pdf
Indicators partially adapted from:
UNICEF. (2011). WASH in schools. New York, UNICEF. http://www.unicef.org/wash/schools/
Additional resources:
Centers for Disease Control and Prevention (CDC). (n.d.) CDC’s global water, sanitation and hygiene (WASH) program
impact. Factsheet. Atlanta, USA, CDC.
http://www.cdc.gov/healthywater/pdf/global/programs/GlobalWASH-Program-Impact-Sept2012.pdf
International Rescue Committee (IRC). (2007).Towards effective programming for WASH in schools: A manual on
scaling up programs for water, sanitation and hygiene in schools. Delft, The Netherlands, IRC International Water and
Sanitation Centre. (TP series; no. 48). http://www.unwater.org/downloads/TP_48_WASH_Schools_07.pdf
Reviewed by Murat Sahin (United Nations Children’s Fund [UNICEF]), Natalie Roschnik (Save the Children) and
Leanne Riley (World Health Organization [WHO]).
Thematic Indicator 2: Worms
Soil-transmitted helminthiasis, commonly known as School-based mass deworming is one of the most cost-
intestinal worms, and schistosomiasis are two of the effective interventions. Moreover, the benefits of a
neglected tropical diseases that affect hundreds of school-based control intervention can accrue to other
millions of school-age children worldwide, with the high risk groups (e.g. preschool children and pregnant
greatest number of infections in sub-Saharan Africa and women) and to the community at large. Long-term
Southeast Asia. Although relatively few deaths are interventions to reduce transmission of worms include:
estimated to be directly attributable to worms, mortality improvements to the water and sanitation situation (see
due to schistosomiasis in rural Africa is probably Thematic Indicator 1: WASH); skills-based hygiene
underestimated and could cause up to 250,000 deaths education focusing on the use of latrines; hand washing
per year. with soap at key times; clean water supply; and
management and supportive school health policies to
The significance of these infections for schoolchildren
encourage behavior change in the school and in the
lies in their chronic effects on health and nutrition. Worm
community.
infections in children aged 2 to 14 years (a time period
when they should be undergoing intense physical and
intellectual growth) has negative effects on growth,
nutritional status (particularly levels of iron and vitamin
A), physical activity, cognitive development, mental
concentration, and school performance. Adolescent girls
are particularly at risk of anemia, aggravated by
parasitic infections. In developing countries, more than
850 million school-age children are at risk of morbidity
due to soil-transmitted helminthiasis or schistosomiasis
(WHO 2011). Schools provide an ideal setting in which
to control these diseases and in this age group.
Worms Indicators Table

Frequency Methods
FRESH PILLARS
1. Existence of a national-level policy recommending school-based Every 2 years Policy analysis
deworming.

See Thematic Indicator 1: WASH

1. Percentage of classes participating in at least one health education Every 2 years School survey
activity (focused on prevention of parasitic infection) (WHO, 2011).
1. Percentage of schools participating in the (deworming) program Annually School monitoring
(WHO, 2011)
2. Deworming coverage (percentage of schoolchildren who received the Annually School monitoring
deworming drug (WHO, 2011) by questionnaire
OUTCOMES
LEARNING
1. Percentage of students and teachers who know the main ways to Every 2 to 3 years KAP (Knowledge,
prevent soil-transmitted helminth infection: use latrines to defecate, Attitudes and
and wash hands with soap at key times. Practices) Survey
2. Percentage of students who know the main ways to prevent Every 2 to 3 years KAP survey
schistosomiasis infection: by not urinating or defecating in water.
BEHAVIORAL
1. Percentage of students and teachers observed washing hands with Annually School survey/
soap after going to the toilet. observation
2. Percentage of students who report usually using the latrine when they Every 2 to 3 years KAP survey
defecate at school and home.
3. Percentage of learners who report not urinating in the water in Every 2 to 3 years KAP survey
the last month.
IMPACT
Parasitological indicators
1. Prevalence of any and each soil-transmitted helminth infection Every 2 to 3 years Stool survey by
(WHO, 2011). health professionals
2. Prevalence of intestinal schistosome infections (WHO, 2011). Every 2 to 3 years Stool survey by
health professionals
3. Prevalence of any hematuria or parasite eggs in urine (WHO, 2011). Every 2 to 3 years Urine survey by
4. Proportion of “heavy intensity” infection with any and each soil- Every 2 to 3 years Stool survey by
transmitted helminths infection (WHO, 2011). health professionals
5. Proportion of “heavy intensity” intestinal schistosome infections Every 2 to 3 years Stool survey by
Morbidity indicators
6. Proportion of children with clinical signs or symptoms (e.g. pot belly) Every 2 to 3 years Clinical survey by
7. Percentage of children with anemia and severe anemia (WHO, 2011). Every 2 to 3 years Clinical survey by

World Health Organization (WHO). (2011). Helminth control in school-age children: A guide for managers of control
programmes – 2nd ed. Geneva, WHO. http://apps.who.int/iris/bitstream/10665/44671/1/9789241548267_eng.pdf
Reviewed by Antonio Montresor and Pamela Mbabazi (WHO); Alan Fenwick (Imperial College London); and
Natalie Roschnik (Save the Children).
Thematic Indicator 3: Food and Nutrition
Rationale (Save the Children, in press). Micronutrient

supplementation is typically given after deworming.
Global nutrition priorities focus on the first 1,000 days of
life since most stunting and long-term consequences of School feeding interventions typically provide school
poor nutrition takes place before a child reaches 3 years meals, snacks or take-home rations to support equitable
of age. However poor nutritional status and hunger access to education among the most vulnerable and
amongst schoolchildren also has serious effects on food-insecure population groups. School feeding can
longer term health and educational outcomes. Hunger help increase school enrolment and attendance
and micronutrient deficiencies, particularly anemia have (especially with girls through take-home rations) and
been shown to negatively affect their ability to improve concentration by addressing short-term hunger,
concentrate in class and attend and complete schooling. cognitive abilities and educational attainment. School
Iron deficiency anemia is one of the most common meals have shown to produce a small, but significant
micronutrient deficiencies amongst school-age children, effect on weight gain and can also help reduce
affecting around 50% of school-age children worldwide micronutrient deficiencies through the use of fortified
(Jukes et al., 2008) and reducing children’s ability to pay foods (Kristjansson et. al., 2009). If the food is produced
attention, participate and learn in school. Micronutrient locally, known as home grown school feeding, it may
deficiencies are caused by a variety of problems also benefit local farmers, producers and processors by
including parasitic infections such as worms and generating a stable, structured, and predictable demand
malaria, and poor quality of diet. Similarly, if a child is for their produce, thereby building the market and
hungry at school, it will affect his or her ability to pay benefiting the wider community.
attention, learn and attend regularly. Children with Nutrition education in schools provides learners with the
adequate diets score higher on tests of factual knowledge, skills and motivation to make wise dietary
knowledge, and among well-nourished people acute and lifestyle choices, building a strong basis for a
illness and disease tends to be less frequent. Healthy healthy and active life. Whether food supplies are scarce
nutrition also contributes to decreasing the risk of or abundant, it is essential that people know how best
leading chronic diseases such as obesity, heart disease, to use their resources to access a variety of safe and
cancer and eating disorders. People who are well- good quality foods, to ensure nutritional well-being.
nourished are also more productive (WHO, 1998). Nutrition education in schools should be participative,
The education system offers a unique opportunity to practical, skills building and adapted to the local context
improve children’s nutritional status and develop healthy and resources available. Children will then learn, for
nutrition behaviors, which in turn can improve the example, how to achieve a good diet with limited
nutrition of girls, future mothers and the next generation means, what food is nutritionally valuable, where to find
of children. it, how to prepare food safely and make it appetizing,
and how to avoid food dangers (FAO, 2005).
Strategies
School gardens can be a powerful tool to improve the
School-based micronutrient supplementation is a highly effectiveness of nutrition education by providing an
cost-effective strategy to address the “hidden hunger” opportunity for children to learn how to grow healthy
of micronutrient deficiencies, particularly iron deficiency food and how to use it for better nutrition. This can best
anemia. WHO recommends intermittent supplementation be done if the fresh garden produce, such as fruits and
with iron amongst preschool and school-age children vegetables, contributes to an existing school feeding
where the prevalence of anemia is over 20% (WHO, program which provides the bulk of the diet. Beyond
2011). Combining iron supplementation with other this, school gardens also serve for environmental
micronutrients such as vitamin A or as a multiple education and for personal and social development by
micronutrient supplement may have additional benefits adding a practical dimension to these subjects
where multiple micronutrient deficiencies are present (FAO, 2010)
Food and Nutrition Indicators Table

Frequency Methods
FRESH PILLARS
1. Existence of a national school nutrition policy. Every 2 years Policy review
2. Existence of a national-level curriculum of standards for health Every 2 years Curricula review
education with a focus on nutrition.
3. Percentage of schools that have or follow a written Every 3 to 5 years Global SHPPS
policy/guideline/rule about the type of foods provided in school meals.
1. Percentage of schools where food for schoolchildren and staff is stored Every 2 years School survey
and/or prepared so as to minimize the risk of disease transmission.
ALTERNATIVE INDICATOR (from global surveys)
1a) Percentage of schools where food preparation staff are required to Every 3 to 5 years Global SHPPS
follow the Five Keys to Safer Food (keep clean; separate raw and
cooked; cook thoroughly; keep food at safe temperatures; use safe water
and raw materials)?

1. Total number of health education sessions focusing on healthy diet and Every 2 to 3 years Curricula review
physical activity per year within the national curriculum.
2. Percentage of schools that provided life skills-based nutrition education Every 2 to 3 years School survey
in the previous term.
3. Percentage of teachers who have received (locally defined minimum Annually Training records
standards of) training in nutrition life skills education. and EMIS
1. Percentage of schools providing micronutrient supplementation in the Annually School activity reports
past year.
2. Percentage of students (by sex) supplemented with micronutrients. Annually School activity reports
3. Number of schoolchildren receiving school meals. Annually Monitoring reports
4. Number of school feeding days as percentage of actual school days. Annually Monitoring reports
5. Planned/delivered ration kilocalories (kcal/child/day). Annually Project documents
6. Planned/delivered ration micronutrient content (child/day). Annually Project documents
7. Cost of school feeding per child per year. Annually Monitoring reports
8. Percentage of schools offering lunch to students midway through the Every 3 to 5 years Global SHPPS
school day.
9. Percentage of schools that offer students fruit or 100% fruit juice Every 3 to 5 years Global SHPPS
during a typical week.
OUTCOMES
LEARNING
1. Percentage of students who know specific facts about nutrition and Every 2 to 3 years Student survey
healthy life styles related to a balanced diet and how to ensure safe
consumption of food and water.
BEHAVIORAL
1. Percentage of students who usually ate fruit three or more times per day Every 3 to 5 years GSHS
during the past 30 days.
2. Percentage of students who usually ate vegetables three or more times Every 3 to 5 years GSHS
per day during the past 30 days.
3. Percentage of students who usually drank carbonated soft drinks less Every 3 to 5 years GSHS
than once per day during the past 30 days.
4. Improved caloric intake in school. Every 2 years Student survey
5. Improved micronutrient intake in school. Every 2 years Student survey

6. Percentage of students who report having improved their diet Every 2 years Student survey
and lifestyle.
IMPACT
1. Prevalence of thinness/wasting (low Body Mass Index (BMI) for age). Every 3 to 5 years Student survey,
(<-2 BMI for age Z-scores), (>=+2 BMI for age z score) GSHS
2. Prevalence of overweight/obesity Every 3 to 5 years Student survey, GSHS
3. Prevalence of micronutrient deficiencies (e.g. anemia). Every 2 years Student survey

Bundy, D.A.P., Burbano, C., Grosh, M., Gelli, A., Jukes, M.C.H., and Drake, L.J. (2010). Rethinking school feeding.
Social safety nets, child development, and the education sector. Directions in Human Development. Washington D.C.,
The World Bank. http://siteresources.worldbank.org/EDUCATION/Resources/278200-1099079877269/547664-
1099080042112/DID_School_Feeding.pdf
Jukes, M.C.H., Drake, L.J., and Bundy, D.A.P. 2008. School health, nutrition and Education for All. Leveling the playing
field. Wallingford, CABI Publishing. http://bookshop.cabi.org/Uploads/Books/PDF/9781845933111/9781845933111.pdf
Kristjansson, B., Petticrew, M., MacDonald, B., Krasevec, J., Janzen, L., Greenhalgh, T., Wells, G.A., MacGowan,
J., Farmer, A.P., Shea, B., Mayhew, A., Tugwell, P. and Welch, V. (2009). School feeding for improving the physical and
psychosocial health of disadvantaged schoolchildren. Cochrane Review. The Cochrane Collaboration.
http://summaries.cochrane.org/CD004676/school-feeding-for-improving-the-physical-and-psychosocial-health-of-
disadvantaged-schoolchildren
Save the Children. (in press). Micronutrient supplementation for school-age children: Rationale, recommendations and
operational considerations. Washington, D.C., Save the Children.
United Nations Food and Agriculture Organization (FAO). (2010). Setting up and running a school garden. Teaching
toolkit. Rome, FAO. http://www.fao.org/docrep/012/i1118e/i1118e00.htm
FAO. (2005). Nutrition education in primary schools: A planning guide for curriculum development. Rome, FAO.
www.fao.org/docrep/009/a0333e/a0333e00.htm
World Health Organization (WHO). (2011). Intermittent iron supplementation in preschool and school-age children.
Geneva, WHO. http://www.who.int/elena/titles/iron_infants/en/index.html
World Health Organization (WHO). (1998). WHO Information Series on School Health. Document four. Healthy nutrition:
An essential element of a health-promoting school. Geneva: WHO.
http://www.who.int/school_youth_health/media/en/428.pdf
For further information on the following topics consult the references and links suggested below:
School Feeding:
Adelman, S.W., Gilligan, D.O. and Lehrer, K. (2008). How effective are food for education programs? A critical
assessment of the evidence from developing countries. Food Policy Review 9. Washington D.C., International Food
Policy Research Institute. www.ifpri.org/sites/default/files/pubs/pubs/fpreview/pv09/pv09.pdf
Gelli, A. (2010). Food provision in schools in low- and middle-income countries: Developing evidence-based program
framework. London, The Partnership for Child Development.
www.child-development.org/Lists/PCD%20Publications/Attachments/60/g_PCD_wp215.pdf
The Nutrition-Friendly Schools Initiative:
World Health Organization (WHO). (2013). Nutrition-Friendly Schools Initiative (NFSI). Geneva, WHO.
www.who.int/nutrition/topics/nut_school_aged/en/
Reviewed by Natalie Roschnik (Save the Children) and Kristie Watson (The Partnership for Child Development [PCD]).
Thematic Indicator 4: Physical Activity
Non-communicable diseases (NCDs) are the leading The World Health Assembly endorsed in 2004 the
cause of death in the world and their impact is growing. “Global Strategy on Diet, Physical Activity, and Health”
A small set of risk factors, including physical inactivity, (WHO, 2013a; WHO, 2013b) Current WHO physical
are responsible for most of the major NCDs (WHO, activity recommendations for children and adolescents
2011). Physical inactivity is the fourth leading risk factor include at least 60 minutes of moderate to vigorous-
for global mortality, and is becoming increasingly intensity physical activity daily, with greater amounts of
prevalent in middle-income countries, due to rapid physical activity than this providing additional health
economic development, urbanization and benefits. Vigorous-intensity activities should be
industrialization (WHO, 2008a; WHO, 2013a). Childhood incorporated, including those that strengthen muscle
obesity is steadily increasing in developing countries, and bone, at least three times per week (WHO, 2010).
especially in urban areas, with 35 million children Schools can support these recommendations by
considered overweight. Overweight children are more modifying school policies and the curriculum to allow for
likely to remain obese into adulthood and to develop more physical activity during the day, and creating or
NCDs, such as diabetes and cardiovascular disease, at a improving physical activity spaces and equipment.
younger age (WHO, 2013b). Schools provide an excellent
setting to increase activity levels among children by
enabling students to acquire knowledge and skills, to
provide students with opportunities to be physically
active through an activity-friendly environment.
Physical Activity Indicators Table

Frequency Methods
FRESH PILLARS
1. Minimum number of physical education sessions per week within the Every 2 years Policy review
national curriculum.
2. Existence of national qualification requirements for physical education Every 2 years Policy review
teachers, for example, presence or development of a “Framework of
Standards” for teachers.
3. Existence of teaching requirements (knowledge, skills and Every 2 years Policy review
understanding; continued professional development; and quality
assurance mechanisms) for physical education in the national
curriculum.
4. Average number of physical education lessons per week in schools.1 Every 2 years Policy review
5. Percentage of schools where students can be excused from physical Every 3 to 5 years Global SHPPS
education for health reasons, cultural reasons, sex, a disability,
academic achievement, or participation in other school activities.
1 Some experts recommend aiming for 120 minutes of physical education per week.
1. Percentage of schools with a safe and clean space for a physical Every 3 to 5 years Global SHPPS
education class.
2. Percentage of schools with a safe and clean outdoor playing field that Every 3 to 5 years Global SHPPS
can be used for recess, sports, a physical education class, or other
physical activity.
3. Percentage of schools with a place where boys and girls can Every 3 to 5 years Global SHPPS
separately and privately change clothes before and after physical
education.
1. Percentage of schools where physical education is taught to both boys Every 3 to 5 years Global SHPPS
and girls.
2. Percentage of schools where most of the physical education classes to Every 3 to 5 years Global SHPPS
students are taught by a physical education teacher or specialist.
3. Percentage of schools where those who teach physical education are Every 3 to 5 years Global SHPPS
provided with physical education curricula, lesson plans, or learning
activities to guide instruction.
4. Percentage of schools where students are taught about Every 3 to 5 years Global SHPPS
recommendations for regular participation in physical activity, including
frequency, intensity, and duration.
5. Percentage of schools where students are taught the value and Every 3 to 5 years Global SHPPS
importance of fair play.
6. Percentage of schools where students are taught basic motor skills Every 3 to 5 years Global SHPPS
and movement patterns needed to perform a variety of physical activities.
7. Percentage of schools where students receive a grade for physical Every 3 to 5 years Global SHPPS
education.
1. Percentage of schools that offer school-sponsored sports teams that Every 3 to 5 years Global SHPPS
compete against teams from other schools.
2. Percentage of schools offering opportunities for students to participate in Every 3 to 5 years Global SHPPS
non-competitive physical activity or recreation clubs.
OUTCOMES
LEARNING
BEHAVIORAL
1. Percentage of students participating in at least 60 minutes of physical Every 3 to 5 years Student survey/GSHS
activity per day during the past 7 days.
2. Percentage of students who went to physical education class on three or Every 3 to 5 years Student survey/GSHS
more days each week during the school year.
3. Percentage of students who spent three or more hours per day during Every 3 to 5 years Student survey/GSHS
a typical or usual day doing sitting activities (excluding hours spent
sitting at school and doing homework).
4. Percentage of students who walked or rode a bicycle to or from school Every 3 to 5 years Student survey/GSHS
during at least 3 of the past 7 days.
IMPACT

UNESCO. (2012). Worldwide survey – quality physical education indicators and basic needs model. Paris, UNESCO.
http://www.unesco.org/new/en/social-and-human-sciences/themes/physical-education-and-sport/cigeps/indicators-
basic-needs/
UNESCO. (n.d.). UNESCO/NWCPEA project on the development of quality physical education/ indicators and basic
needs model. Paris, UNESCO.
http://www.unesco.org/new/fileadmin/MULTIMEDIA/HQ/SHS/pdf/nwcpea_unesco_survey.pdf
Additional resources:
World Health Organization (WHO). (2013a). Global strategy on diet, physical activity and health: Physical activity.
Geneva, WHO. http://www.who.int/dietphysicalactivity/pa/en/
World Health Organization (WHO). (2013b). Global strategy on diet, physical activity and health: Childhood overweight
and obesity. Geneva, WHO. http://www.who.int/dietphysicalactivity/childhood/en/
World Health Organization (WHO). (2011). Non-communicable diseases and mental health: Global status report on
non-communicable diseases 2010. Geneva, WHO. http://www.who.int/nmh/publications/ncd_report2010/en/
World Health Organization (WHO). (2010). Global recommendations on physical activity for health. Geneva, WHO.
http://whqlibdoc.who.int/publications/2010/9789241599979_eng.pdf
World Health Organization (WHO). (2008a). Review of best practice in interventions to promote physical activity in
developing countries. Geneva, WHO. http://www.who.int/dietphysicalactivity/bestpracticePA2008.pdf
World Health Organization (WHO). (2008b). School policy framework. Implementation of the WHO global strategy on
diet, physical activity and health. Geneva, WHO. http://www.who.int/dietphysicalactivity/SPF-en-2008.pdf
World Health Organization (WHO). (2007). WHO Information Series on School Health. Document twelve. Promoting
physical activity in schools: An important element of a health-promoting school. Geneva, WHO.
http://www.who.int/school_youth_health/resources/information_series/FINAL%20Final.pdf
Reviewed by Timothy Armstrong, Leanne Riley, Godfrey Xuereb, and Hilda Muriuki (WHO); and Jannine Thompson
(United Nations Educational, Scientific and Cultural Organization [UNESCO]).
Thematic Indicator 5: Malaria
Rationale
Children under the age of 5 years and pregnant women Yet, while countries continue to strive to reduce and
are the primary targets for most malaria control eventually eliminate malaria, school-age children which
programs. These populations experience the most acute represent 26% of the population in Africa, are the least
symptoms of malaria, and cases are more likely to likely to sleep under bed nets or seek treatment. This is
result in mortality. However, school-age children are the a situation that can no longer be ignored.
age group most likely to be infected with malaria
parasites. Studies in Kenya, Mali, Malawi and Senegal Strategies
found rates of malaria in school-age children of up to
Schools offer a cost-effective system through which to
80%, most of which are asymptomatic cases that never
control malaria amongst schoolchildren and the wider
get treated (Roschnik, 2013). If untreated, these
community. School-based activities include skills-based
infections can result in anemia and reduce children’s
malaria prevention education, promotion and distribution
ability to concentrate and learn in school (Brooker, 2009;
of insecticide-treated nets (ITNs), and school-based
Brooker et al., 2008). Both asymptomatic malaria
treatment for malaria (although the latter requires more
parasitism and clinical malaria contribute up to 50% of
research). Boarding schools should ensure that children
all preventable school absenteeism and 4 to 10 million
sleep under ITNs throughout the malaria transmission
school days lost per year (Brooker, 2009).
season; that screens are present on doors and windows
of boarding houses to reduce the entry of mosquitoes
Malaria also remains one of the biggest killers of
into dormitories, and that school dormitories are
school-age children, estimated to cause up to 50% of all
targeted by Indoor Residual Spraying activities. Strong
deaths in this age group in Africa (Brooker, 2009). In
links or partnerships with local health care facilities
pregnancy, malaria is a major cause of low birth weight
could help with the referral and treatment of students
and maternal anemia and can even result in maternal
with malaria.
death. In Mozambique, for example, 27% of deaths in
adolescent pregnant girls were caused by malaria
(Brooker, 2009).
Malaria Indicators Table

Frequency Methods
FRESH PILLARS
1. Malaria control in schools features in a national-level policy or strategy Every 2 years Policy review
e.g. the national malaria control policy or strategy and/or the national
school health policy or strategy.
2. Percentage of schools with a written policy, plan or guide for malaria Every 2 years School survey or
control. interview
3. Percentage of schools that have implemented at least two planned Every 2 years School survey
malaria control activities.

1. Percentage of boarding schools that have malaria control measures in Every 2 years School survey
place to protect children at night e.g. ITNs over beds and/or Indoor
Residual Spraying (in the last 6 months).
2. Percentage of schools that have removed mosquito breeding sites on Every 2 years School survey
school grounds.

1. Essential malaria prevention messages are present in the national Every 2 years Curriculum analysis
primary school curriculum.
2. Essential malaria prevention messages are present in the national Every 2 years Curriculum analysis
secondary school curriculum.
3. Percentage of classes that gave at least one malaria prevention lesson Every 2 years School survey
in the past year.
4. Percentage of schools that organized a locally relevant malaria Every 2 years School survey
campaign that involved parents, children and community members.
1. Percentage of schools that support a universal ITN distribution Every 2 years School survey
campaign.
2. Percentage of students that have access to ITNs or long-lasting Every 2 years School survey
insecticide-treated nets at home.
3. Percentage of schools with a mechanism in place for identifying and Every 2 years School survey
treating (or referring) sick children for malaria.
OUTCOMES
LEARNING
1. Percentage of students who know how malaria is transmitted, Every 2 years Student survey
prevented and treated.
BEHAVIORAL
1. Percentage of students who report sleeping under a mosquito net the Every 2 years Student survey
night before.
2. Percentage of students who report seeking treatment promptly (within Every 2 years Student survey
24 hours of onset of symptoms) the last time they had fever.
IMPACT
1. Percentage of children infected with malaria parasitaemia. Every 4 to 5 years Survey of school
children
2. Percentage of children with anemia. Every 4 to 5 years Survey of school
children

Brooker, S. (2009). Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa.
PCD, LSHTM, KEMRI-Wellcome Trust and the World Bank. Kenya, KEMRI-Wellcome Trust.
http://www.schoolsandhealth.org/Documents/Malaria%20Toolkit%20for%20Schools%202009.pdf
Brooker, S., Clarke, S., Snow, R.W. and Bundy, D.A.P. (2008). Malaria in African schoolchildren: Options for control.
Transactions of the Royal Society of Tropical Medicine and Hygiene, 102(4-4): 304-305.
http://researchonline.lshtm.ac.uk/8136/1/main.pdf
Roschnik, N. (2013). Malaria control in schools in Mali: Results from a cluster randomized control trial in Sikasso
Region. Mali. Save the Children.
http://www.schoolsandhealth.org/Documents/Malaria%20control%20in%20schools%20in%20Mali%20(English).pdf
World Health Organization (WHO). (2007). WHO Information Series on School Health. Document thirteen. Malaria
prevention and control: An important responsibility of a health-promoting school. Geneva: WHO.
http://www.who.int/chp/topics/healthpromotion/MALARIA_FINAL.pdf
Reviewed by Sian Clarke and Simon Brooker (London School of Hygiene and Tropical Medicine); Andy Tembon and
Donald Bundy (World Bank); and Natalie Roschnik (Save the Children).
Thematic Indicator 6: Oral Health
The most common chronic diseases in children It is essential that promotion of oral health be
worldwide are dental caries (tooth decay) and gum incorporated into other school health activities. School
disease (gingivitis). Across the world, 60% to 90% of health promotion which includes intervention towards
schoolchildren are affected by dental caries and nearly healthy diet and nutrition, improving personal hygiene,
all children present gingival bleeding as the major controlling tobacco use and alcohol consumption, and
symptom of gum disease. Most dental caries in children preventing accidents may prevent disease of teeth and
remains untreated and may have general health mouth among schoolchildren. There are, however,
consequences. Diseases of teeth and mouth affect specific oral health measures that need to be
children’s ability to eat and chew, the food they choose, addressed, mainly the adequate exposure to fluoride for
their appearance and the way they communicate. Pain the prevention of dental caries, the relief of pain from
from teeth and the mouth can compromise children’s teeth and the mouth and, where possible, appropriate
attention and their ability to work at school, thereby prevention-focused dental care either at school or at
hampering, not only their play and development, but community-based dentists.
also denying them the full benefit of schooling. Other
A number of thematic indicators provided in other
oral conditions commonly seen are trauma of teeth and,
sections (such as Thematic Indicator 2: Food and
in children infected with HIV, specific oral lesions.
Nutrition; Thematic Indicator 10: Injury Prevention;
The essential risk factors involved with mouth disease Thematic Indicator 11: HIV and AIDS; and Thematic
among children and young individuals relate to an Indicator 13: Substance Abuse) are also pertinent to oral
unhealthy diet, in particular high and frequent health and are therefore, not repeated here. This section
consumption of sugars, poor oral hygiene, use of rather complements them with supplementary oral
tobacco and alcohol. Sugars may be consumed in the health indicators, both at the outcome and process-
form of sweets and sugary soft drinks, meanwhile level.
several regular food items are also rich in sugars.
Contributing factors to mouth diseases relate to
suboptimal levels of fluoride in drinking water, lack of
school-based fluoride programs, and limited availability,
if any, of fluoride toothpaste for oral hygiene. Major
barriers to school-based oral health promotion are lack
of sanitary facilities and clean water, lack of experience
in promoting health and prevention of mouth diseases
among schoolteachers, lack of health education tools,
and isolation of oral health from the school curricula. In
addition, lack of school health services may limit the
control of mouth diseases of schoolchildren. Lack of
referral of children for dental care is another factor
which may limit prevention and treatment of mouth
diseases. Experiences across the world have shown that
formulations of oral health policies at national- and
school-levels are important to the development of well-
functioning school oral health programs. In a number of
countries school oral health is organized according to
the WHO Health Promoting Schools concept.
Oral Health Indicators Table

Frequency Methods
FRESH PILLARS
1. Existence of a national policy recommending strategies to address oral Every 3 years Policy review
health problems in schools.
2. Percentage of schools with a curriculum incorporating oral health. Every 3 years National- and school-
levels
1. Percentage of schools where the provision of foods and drinks high in Every 3 years School survey –
sugars is banned. questionnaire
2. Percentage of schools providing healthy drinks and fruits. Every 3 years School survey –
questionnaire
3. Percentage of schools with appropriate sanitary facilities for personal Every 3 years School survey –
and oral hygiene. questionnaire

1. Percentage of schools having established programs for daily tooth Every 3 years School survey –
brushing with fluoridated toothpaste. questionnaire
2. Percentage of schools providing oral health education focusing on Every 3 to 5 years School survey
healthy lifestyles, appropriate diet, and nutrition. questionnaire/Global
SHPPS
1. Percentage of schools providing oral health protection activities, such Every 3 years School survey –
as fluoride administration and fissure sealing. questionnaire
2. Percentage of schools having established oral health care services, or Every 3 years School survey –
systems for screening/referral for dental care. questionnaire/ Global
SHPPS
OUTCOMES
LEARNING
1. Percentage of students who know key ways to prevent oral disease. Every 3 years School survey –
questionnaire
BEHAVIORAL
1. Percentage of students who undertake daily tooth brushing with Every 3 years School survey –
fluoridated toothpaste while at school. questionnaire
2. Percentage of students not consuming sugary items while at school. Every 3 years School survey –
questionnaire
IMPACT
1. Percentage of students at a certain age with no dental caries. Every 5 years School survey _
clinical examination /
WHO Oral Health
Surveys
2. Percentage of students at a certain age with no bleeding gums Every 5 years School survey _
(gingivitis). clinical examination /
WHO Oral Health
Surveys
3. Percentage of students with experience of pain/discomfort from the Every 5 years School survey _
teeth or mouth within the past year. clinical examination /
WHO Oral Health
Surveys
4. Number of school days missed in the past year due to oral health Every 5 years School survey –
problems. questionnaire

Benzian, H. and Monse B. (2011). Promoting Oral Health. In: Bundy D.A.P., Rethinking school health: A key component
of Education for All. Chapter 3, page 111. Washington D.C., World Bank Publications, 2011. http://www-
wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2011/03/09/000356161_20110309020432/Rendere
d/PDF/600390PUB0ID171Health09780821379073.pdf
Jürgensen, N. and Petersen, P.E. (2012). Global survey on oral health through schools. Geneva. WHO.
Kwan, S.Y.L., Petersen, P.E., Pine, C.M. and Borutta, A. (2005). Health-promoting schools: An opportunity for oral health
promotion. Bulletin of the World Health Organization, 83(9): 677-685.
Petersen, P.E. (2003). The World Oral Health Report 2003: Continuous improvement of oral health in the 21st century –
the approach of the WHO Global Oral Health Programme. Community Dental and Oral Epidemiology, 31(1): 3-24.
Petersen, P.E. and Torres, A,M. (1999). Preventive oral health care and health promotion provided for children
and adolescents by the Municipal Dental Health Service in Denmark. International Journal of Paediatric Dentistry,
9(2): 81-91.
World Health Organization (WHO). (2003a). WHO Information Series on School Health. Document eleven. Oral health
promotion: An essential element of a health-promoting school. WHO, Geneva.
http://www.who.int/oral_health/media/en/orh_school_doc11.pdf
World Health Organization (WHO). (2003b). Diet, nutrition and the prevention of chronic diseases. World Technical
Report Series 916. Geneva, WHO. http://whqlibdoc.who.int/trs/who_trs_916.pdf
World Health Organization (WHO). (1997). Oral Health Surveys: Basic methods. 4th ed. Geneva, WHO.
Reviewed by Habib Benzian (Fit for School International); Bella Monse (Deutsche Gesellschaft fuer Internationale
Zusammenarbeit); and Poul Erik Petersen (WHO).
Thematic Indicator 7: Eye Health
Around the world, an estimated 19 million children are School eye programs need to be comprehensive,
visually impaired and are officially classified as either integrated within school health initiatives, monitored and
blind or with low vision. Of these, 12 million children are evaluated, and cost-effective. Components of
visually impaired due to refractive errors, which is a comprehensive school eye health programs include:
condition that could be easily diagnosed and corrected education about eye conditions and eye health; primary
with a pair of spectacles. In addition to refractive errors, eye care for children-including identification of children
primary school-age children may be affected by allergic in need of spectacles; eye care for teachers; a health
eye disease, conjunctival infection, including trachoma, promoting school environment; a child-to-child
and eye injuries. Some children may have more serious approach; and links to control programs for local
conditions which require surgery, such as cataract. endemic diseases (Gilbert, n.d.).
Other children may have conditions associated with
Strong links with special needs education services are
permanent vision loss i.e. they have low vision (WHO,
also required to ensure that children who are identified
1993) and require devices such as magnifiers, or better
as blind, and thus, cannot learn using visual methods,
lighting to enable them to read. School health programs
receive more specialized support needed to realize their
can play a role in prevention, detection and/or referral
rights to education, preferably within an inclusive local
for treatment for these conditions, and supporting
environment.
children with low vision.
In addition, schoolchildren can play a role in improving
the eye health of the community and in their families by
taking health messages and ideas back home about
conditions that may affect preschool age children’s eye
health such as vitamin A deficiency and infectious eye
diseases such as trachoma (Gilbert, 2011) where the
condition is endemic.
Eye Health Indicators Table

Frequency Methods
FRESH PILLARS
1. Existence of a national policy recommending strategies to address eye Every 2 years Policy review
and vision problems in schools.
2. Percentage of schools implementing a policy on promotion of eye health Every 2 years Health and school
education authorities
1. Percentage of schools where clean water for face and hand washing Every 2 years School survey/
is available, to reduce trachoma transmission. observation
2. Percentage of schools where special seating is arranged (e.g. in front Every 2 years School survey/
of the class or by a window for better light) for children with low vision. observation

1. Percentage of schools that include eye health education in their curriculum. Every 2 years School survey
2. Percentage of schools providing eye health education. Every 2 years School survey
1. Percentage of schools where most of the students are screened at Every 3 to 5 years Global SHPPS
school for vision problems.
2. Percentage of schools where referrals for vision problems are provided Every 3 to 5 years Global SHPPS
at school.
OUTCOMES
LEARNING
1. Percentage of students who know key ways to prevent eye diseases Every 2 years Student survey
including locally endemic infectious diseases.
BEHAVIORAL
1. Percentage of students who have participated in an event to promote Every 2 years Student survey
eye health to family and community members.
2. Percentage of students prescribed spectacles or low vision devices Every 2 years School survey /
who use them in class. observation
3. Enrolment, attendance and completion rates of children in school who Every 2 years School and medical
have been diagnosed with blindness or low vision and who are records
receiving appropriate interventions.
IMPACT
1. Percentage of students with untreated vision problems. Every 2 years School records /
medical records
2. Performance (exams, etc.) of students who have been diagnosed with Every 2 years School records
blindness or low vision and received appropriate interventions.
3. Rates of vitamin A deficiency and active trachoma (grade TF) in the Every 5 years Ministry of Health and
community. neglected tropical
diseases / trachoma
control programs

Gilbert, C. (2011). IAPB Briefing Paper: Integrating eye health into school health programs. London, IAPB.
http://www.iapb.org/sites/iapb.org/files/Eye%20health%20%26%20Schools%20IAPB%20BP.pdf
Gilbert, C. (n.d.). Comprehensive school eye health programs. (Power point presentation.) London, IAPB.
http://www.iapb.org/assembly/course-19-eye-health-children
International Agency for the Prevention of Blindness (IAPB). (n.d.). Course 19: Eye Health for Children. London, IAPB.
http://www.iapb.org/assembly/course-19-eye-health-children
World Health Organization (WHO). (2012). Visual impairment and blindness. Fact Sheet No 282. Geneva, WHO.
http://www.who.int/mediacentre/factsheets/fs282/en/index.html
World Health Organization (WHO). (2006). A guide: Trachoma prevention through school health curriculum
development. Alleviating human suffering through education and empowerment. Geneva, WHO.
http://www.who.int/blindness/CHF%20GUIDE%20FINAL%20EN.pdf
World Health Organization (WHO). (1993). Management of low vision in children. Report of a WHO Consultation.
Bangkok 23-24 July 1992. Geneva, WHO. http://whqlibdoc.who.int/hq/1993/WHO_PBL_93.27.pdf
Reviewed by Peter Ackland (International Agency for the Prevention of Blindness).
Thematic Indicator 8: Ear and Hearing
Recent WHO estimates reveal that 32 million children Prevention strategies which could be offered through
across the world live with disabling hearing loss. One of schools include immunizing school-age children against
the main impacts of hearing loss is on a child’s ability to childhood diseases such as measles, meningitis, rubella
communicate with others. Spoken language and mumps, and immunizing adolescent girls against
development is often delayed in children with deafness. rubella (WHO, 2012). In addition, screening of young
Hearing loss and ear diseases such as otitis media can children for early detection of ear diseases and hearing
have significantly adverse effects on the academic loss should occur upon school entry and could be
performance of children (WHO, 2012). Half of all cases incorporated into a school health screening program.
of hearing loss and deafness are avoidable through Children that screened positively can be targeted for
primary prevention, and many can be treated through simple classroom measures to improve their progress in
early diagnosis and suitable management (WHO, 2012). schools and to raise the level of awareness in the school
and community (WHO, 2006).
Strong links with special needs education services are
also beneficial to ensure that children who are identified
as hearing impaired receive specialized support to fully
realize their rights to education, preferably within an
inclusive local environment.
Ear and Hearing Indicators Table

Frequency Methods
FRESH PILLARS
1. Existence of a national policy recommending strategies to address ear Every 2 years Policy review
and hearing problems in schools.
1. Existence of special arrangements (e.g. seating in front of the class or Every 2 years School survey/
suitable lighting, etc.) for children with hearing problems. observation
1. Percentage of schools that include ear and hearing care education in Every 2 years School survey
their curriculum.
1. Percentage of schools carrying out ear and hearing screening. Every 2 years School survey
2. Percentage of schools with an effective strategy for addressing ear Every 2 years School survey
and hearing problems (e.g. referral to a health center for further tests
and follow-up).
3. Number of children referred for ear and hearing problems. Annually School survey
OUTCOMES
LEARNING
1. Percentage of students who know key ways to prevent and care for Every 2 years Student survey
hearing loss.
BEHAVIORAL
1. Percentage of students who have participated in an event to promote Every 2 years Student survey
healthy ear and hearing care habits in the family and community.
2. Percentage of teachers who have participated in a training program or Every 2 years School records
event regarding ear and hearing care.
3. Number of children ‘treated’ for ear and hearing problems. Every 2 years Medical records
IMPACT
1. Percentage of children with hearing loss. Every 2 years School records /

medical records
2. Percentage of children with untreated ear and hearing problems. Every 2 years School records /
medical records

Save the Children. (2008). Vision and hearing screening in schools. Successes and lessons from Mangochi District,
Malawi. Washington D.C., Save the Children.
http://www.schoolsandhealth.org/documents/vision_and_hearing_screening_in_schools-
lessons_learned_from_malawi.pdf
World Health Organization (WHO). (2013a). Prevention of blindness and deafness. Primary ear and hearing care.
http://www.who.int/pbd/deafness/activities/hearing_care/en/index.html
World Health Organization (WHO). (2013b). Deafness and hearing loss. Fact sheet No. 300. Geneva: WHO.
http://www.who.int/mediacentre/factsheets/fs300/en/
World Health Organization (WHO). (2012). WHO global estimates on prevalence of hearing loss. Geneva: WHO.
http://www.who.int/pbd/deafness/WHO_GE_HL.pdf
World Health Organization (WHO). (2006). Primary ear and hearing care training resource. Advanced-level. Geneva, WHO.
http://www.who.int/pbd/deafness/activities/hearing_care/advanced.pdf
Reviewed by Shelly Chadha (WHO).
Thematic Indicator 9: Immunization
Immunization is a proven intervention for controlling and Immunization has clearly defined target groups spanning
eliminating life-threatening infectious diseases and is the life-cycle from infants and children, to adolescents
estimated to prevent over 2.5 million deaths each year. and adults. Traditional immunization programs have
Immunization also reduces long-term disability among included vaccines against diphtheria, tetanus, pertussis,
children due to certain vaccine-preventable illnesses, measles, polio, and tuberculosis. Over the past decade,
thereby reducing clinic visits as well as hospitalization these programs have begun adding vaccines against
(WHO, UNICEF and World Bank, 2009). Immunization is hepatitis B, influenza, mumps, pneumococcal disease,
one of the most cost-effective health investments, with rotavirus, and rubella as well (WHO, UNICEF and World
fixed-site, outreach, mobile and campaign style Bank, 2009). Enrolment at school provides the
strategies that make it accessible to even the most opportunity to screen children and adolescents for
hard-to-reach and vulnerable populations. Since the vaccination status and the location itself can serve as a
Millennium Development Goals, school enrolment rates delivery site for providing booster doses and other
have been increasing, making school immunization a recommended childhood and adolescent vaccinations
promising opportunity to reach a large number of (for example, diphtheria, tetanus, pertussis [DTP]
children. boosters, tetanus toxoid, measles, rubella, human
papillomavirus, influenza, etc.).
Immunization also serves as an opportunity to deliver
other life-saving measures, such as vitamin A
supplements to prevent malnutrition, ITNs for protection
against malaria, and deworming drugs for intestinal
worms.
Immunization Indicators Table

Frequency Methods
FRESH PILLARS
1. Existence of a national-level policy recommending school entry Every 2 years Policy review
screening for vaccination status.
2. Percentage of schools that require students to be in compliance with Every 3 to 5 years Global SHPPS
the national immunization schedule for school enrolment.

1. Percentage of students reporting they received at least one health Every 2 years School survey
education session per academic year focused on vaccine-preventable
diseases and immunization.
2. Percentage of schools that provide information to students and families Every 3 to 5 years Global SHPPS
about the value and importance of receiving routine immunizations to
prevent infectious disease.
1. Percentage of schools implementing screening of vaccination status of Every 2 years School survey
students at enrolment.
2. Percentage of schools providing booster doses and other Every 2 years School survey
recommended childhood vaccinations.
ALTERNATIVE INDICATOR (from global surveys)

2a). Percentage of schools providing routine immunizations at school. Every 3 to 5 years Global SHPPS
OUTCOMES
LEARNING
BEHAVIORAL
1. Percentage of school-age children/ adolescents who received the Annually Administrative

nationally recommended vaccinations planned to be given at school. records/data
IMPACT
1. Age-specific (e.g. school-age) incidence rate of measles and Annually Disease

diphtheria (or the number of outbreaks of measles and diphtheria in surveillance data
schools).
World Health Organization (WHO). (2012). WHO recommendations for routine immunization – summary tables. Geneva,
WHO. http://www.who.int/immunization/policy/immunization_tables/en/index.html
World Health Organization (WHO). (2011). Immunization service delivery: School-based immunization. Geneva, WHO.
http://www.who.int/immunization_delivery/systems_policy/school-based-immunization/en/
World Health Organization (WHO), UNICEF and World Bank. (2009). State of the world’s vaccines and immunization.
Third edition. Geneva, WHO. http://www.unicef.org/immunization/files/SOWVI_full_report_english_LR1.pdf
Reviewed by Tracey Goodman and Leanne Riley (WHO).
Thematic Indicator 10: Injury Prevention
Child injuries are a growing global problem. Each year There are proven ways to reduce the likelihood and
close to 400,000 children die from unintentional injuries severity of each area of unintentional child injury. Basic
alone, such as traffic injuries, drowning, poisonings, principles that underlie most successful child injury
burns and falls. Unintentional injuries are the leading prevention programs in schools include: environmental
cause of death for children aged 10 to 19 years in low- modification of playground and other indoor and outdoor
income and middle-income countries and children aged facilities; promotion of safety devices (e.g. helmets and
5 to 19 years in high-income countries. In addition, seat-belts); development and implementation of
millions of others suffer from non-fatal injuries which standards for school safety (e.g. zebra crossing and
often lead to disability and other lifelong consequences. appropriate type and depth of playground surface
The young age of schoolchildren, the stage of their material); and health education and life skills
development and the manner with which they interact development (e.g. first aid and swimming lessons).
with the world make children especially susceptible to Standardization of safety education curricula increases
injuries (WHO and UNICEF, 2008). As outlined in the the likelihood that all children will receive similar
Convention of the Rights of the Child (OHCHR, 2013), information. Adoption of standardized safety curricula
ratified by almost all governments, countries have the into national policy will increase the likelihood that the
responsibility and obligation to protect and ensure safety curricula will be used by all schools. Child injury
in the care and protection of children. prevention should be shared between many sectors and
integrated into a comprehensive approach to child
health and development (WHO and UNICEF, 2008).
Injury Prevention Indicators Table

Frequency Methods
FRESH PILLARS
1. Existence of a comprehensive national child health strategy or a Every 3 to 5 years Policy review
national injury prevention strategy that includes prevention of injuries
at school.
2. Percentage of schools with a system to routinely monitor Every 3 to 5 years Global SHPPS
implementation of school-based injury prevention policy.

1. Existence of a local road safety strategy, including a focus on children. Every 3 to 5 years Key informant
interview
2. Percentage of schools that had playground or athletic facilities and Every 3 to 5 years Global SHPPS
equipment inspected and provided with appropriate maintenance
during the past 12 months.
3. Percentage of schools that had school structures and buildings Every 3 to 5 years Global SHPPS
inspected for safety issues and hazards (such as broken windows,
water leaks or outdoor landscape hazards) and provided with
appropriate maintenance during the past 12 months.
4. Percentage of schools that had school grounds inspected for safety Every 3 to 5 years Global SHPPS
issues and hazards (such as overgrown landscaping, refuse, or
garbage) and provided with appropriate maintenance during the past
12 months.
5. Percentage of schools with trained teacher(s) to monitor and Every 3 to 5 years Global SHPPS
administer first aid and basic safety.
1. Percentage of schools who have curricula on first aid. Every 3 to 5 years Global SHPPS
2. Percentage of students taught about injury prevention and safety, for Every 3 to 5 years Global SHPPS
example, road safety.
3. Percentage of students exposed to school curricula recommending Every 3 to 5 years GSHS
how to prevent motor vehicle accidents.
4. Percentage of students exposed to school curricula recommending Every 3 to 5 years GSHS
how to avoid or prevent other types of accidents, such as fires,
drowning or poisoning.
OUTCOMES
LEARNING
BEHAVIORAL
1. Percentage of students wearing a seat belt when seated in a car or Every 3 to 5 years GSHS
other motor vehicle driven by someone.
2. Percentage of students wearing a seat belt when driving a car or other Every 3 to 5 years GSHS
motor vehicle.
3. Percentage of students wearing a helmet when riding a bicycle. Every 3 to 5 years GSHS
IMPACT
1. Percentage of students reporting they had fall-related injuries in the Every 3 to 5 years GSHS
past 12 months.
2. Percentage of students reporting they had motor vehicle-related Every 3 to 5 years GSHS
injuries in the past 12 months.
3. Percentage of students reporting they had fire-related injuries in the Every 3 to 5 years GSHS
past 12 months.
UNICEF and World Health Organization (WHO). (2008). Have fun, be safe! Companion to the world report on child injury
prevention. New York, UNICEF. http://www.unicef.org/publications/files/Have_Fun_Be_Safe.pdf
United Nations Office of the High Commissioner for Human Rights (OHCHR). (2013). Convention on the rights of the
child. Geneva, OHCHR. http://www.ohchr.org/EN/ProfessionalInterest/Pages/CRC.aspx
World Health Organization (WHO). (2013). Global school-based student health survey (GSHS). Chronic Diseases and
Health Promotion. Geneva, WHO. http://www.who.int/chp/gshs/en/
World Health Organization (WHO) and UNICEF. (2008). World report on child injury prevention. Edited by Peden,
M., Oyegbite, K., Ozanne-Smith, J., Hyder, A.A., Branche, C., Fazlur Rahman, A.K.M., Rivara F. and Bartolomeos,
K. Geneva, WHO. http://whqlibdoc.who.int/publications/2008/9789241563574_eng.pdf
Reviewed by Kidist Bartolomeos and Leanne Riley (WHO).
Thematic Indicator 11: HIV and AIDS
There are 2.5 million children under age 15 and 5 School-based HIV and AIDS education can reach many
million young people aged 15 to 24 living with HIV. Only children with factual HIV information and equip them
28% of children needing antiretroviral medication with the knowledge and skills to protect themselves
received it. In 2009, an estimated 890,000 new HIV before becoming sexually active. When young people
infections occurred among young people. Some regions learn about sex and HIV before their sexual debut, their
have higher HIV burden than others. In Southern Africa, risk of contracting HIV is reduced. School-based sex and
nine countries have at least 1 in 20 young people living HIV education have been shown to reduce sexual risk
with HIV. Globally, more young females are infected with behaviors, increase knowledge, and improve attitudes
HIV than young males, and in many countries women toward changing HIV-risk behaviors among students
face their greatest risk of infection before age 25 (IATT, n.d.).
(UNICEF, 2010).
Life skills education is an effective methodology which
Over the past decade the education sector has played uses participatory exercises to teach behaviors to young
an increasingly important role in the multisectoral people that help them deal with the challenges and
response to HIV and AIDS. The priority placed on the demands of everyday life. It can include decision making
education sector’s response is based on the evidence and problem solving skills, creative and critical thinking,
that education contributes to knowledge and personal self-awareness, communication and interpersonal
skills essential for HIV prevention and that it protects relations. It can also teach young people how to cope
individuals, communities and nations from the impact of with their emotions and causes of stress. When adapted
AIDS. However, as resources for multisectoral responses specifically for HIV education in schools, a life skills-
to HIV become ever more limited, it becomes crucial that based approach helps young people understand and
the education sector is able to show evidence of the assess the individual, social and environmental factors
impact of its responses to the HIV epidemic. that raise and lower the risk of HIV transmission. When
properly implemented, it can have a positive effect on
behaviors, including delay in sexual debut and reduction
in number of sexual partners.
Schools can play a supportive role in treatment and care
for young people living with or affected by HIV. They can
facilitate HIV treatment education and access to
preventive services, such as voluntary counseling and
testing. Additionally, they can provide or refer students
to psychosocial support services (IATT, n.d.). For girls,
education itself contributes to many factors associated
with decreased risk of HIV infection, such as delayed
marriage, use of family planning, and economic
independence (IATT, n.d.).
HIV and AIDS Indicators Table

Frequency Methods
FRESH PILLARS
1. National Commitments and Policy Instruments (NCPI) Every 2 years Questionnaire
administered to
government officials
and representatives
from civil society.
(Global AIDS Response
Progress [GARP]
indicator #7.1/formerly
United Nations General
Assembly Special
Session [UNGASS]
indicator #2).

1. Percentage of schools that provided life skills-based HIV and sexuality Every 2 years EMIS annual school
education in the previous academic year. census or school-
based survey targeting
school principals.
(Based on former
UNGASS indicator
#11). / Global SHPPS
2. Percentage of schools with teachers who received training and also Every 2 years EMIS annual school
taught lessons in life skills-based HIV and sexuality education in the census targeting
previous academic year. school principals
3. Percentage of schools that provided an orientation process for parents Every 2 years EMIS annual
or guardians of students regarding life skills-based HIV and sexuality school census
education programs in schools in the previous academic year.
1. Percentage of schools with HIV counseling, testing or referrals Every 3 to 5 years Global SHPPS
provided at school.
2. Percentage of orphaned and vulnerable children aged 5 to17 years, Every 2 years EMIS annual school
who received emotional or psychological support through schools. census targeting
principals.
(Recommended for
countries with
generalized HIV
epidemics).
3. Percentage of orphaned and vulnerable children, aged 5 to 17 years, Every 2 years EMIS annual school
who receive bursary support, including free exemptions, through census. (Recommended
schools. for countries with
generalized HIV
epidemics).
4. Percentage of educational institutions that implement an HIV Every 2 years School- and college-
Workplace Program. based survey or EMIS
annual school/college
census. (Recommended
for countries with
generalized HIV
epidemics).
5. Percentage of orphaned and vulnerable children, aged 5 to 17 years, Every 2 years EMIS annual school
who receive social support, excluding bursary support, through census. (Recommended
schools. for countries with
generalized HIV
epidemics).
OUTCOMES
LEARNING
1. Percentage of students aged 10 to 24 years, who demonstrate desired Every 2 years Household survey, in-
knowledge-levels and reject major misconceptions about HIV and out-of-school
transmission. youth. Possibility of
using student survey
in schools. (from
revised Inter-Agency
Task Team [IATT]
indicator)
BEHAVIORAL
1. Percentage of young people aged 15 to 24 years, who have had Every 4 to 5 years Population-based
sexual intercourse before the age of 15 years. surveys, DHS or MICS.
(GARP indicator
1.2/former UNGASS
indicator #15)
2. Percentage of women and men, aged 15 to 49 years, who have had Every 4 to 5 years Population-based
more than one partner in the past 12 months and who used a condom surveys, DHS or
during their last sexual intercourse. MICS. (from revised
IATT indicator,
GARP indicator
1.4/former UNGASS
indicator #17)
IMPACT
1. Percentage of students who permanently left school due to HIV-related Annually EMIS annual school
illness or death in the previous academic year. census questionnaire.
(Recommended for
countries with
generalized HIV
epidemics).
2. Current school attendance among orphans and non-orphans Preferred: every Population-based
aged 10 to 14 years. 2 years Minimum: surveys (DHS, AIDS
Every 4 to 5 years Indicator Survey, MICS
or other representative
survey). (Recommended
for countries with
generalized HIV
epidemics). (GARP
indicator 7.3/former
UNGASS indicator #12)
3. Teacher attrition rate in the previous academic year due to HIV and AIDS. Every 2 years EMIS annual school
census questionnaire

The indicators are based on the ones field-tested by UNESCO and endorsed by the Joint United Nations Programme
on HIV/AIDS (UNAIDS) IATT on Education and the GARP Reporting 2012.
For more information:
UNAIDS. (2011). Global AIDS response progress (GARP) reporting 2012. Guidelines: Construction of core indicators for
monitoring the 2011 Political Declaration on HIV/AIDS. Geneva, UNAIDS.
http://www.unaids.org/en/media/unaids/contentassets/documents/document/2011/JC2215_Global_AIDS_Response
_Progress_Reporting_en.pdf
UNESCO. (2013). Global monitoring and evaluation framework for comprehensive education responses to HIV and
AIDS: Guidelines for the construction of core indicators. Paris, UNESCO.
Inter-Agency Task Team [IATT] on HIV and Young People. (n.d.) Guidance brief: HIV interventions for young people in
the education sector. New York: UNFPA. http://www.unfpa.org/hiv/iatt/docs/education.pdf
UNICEF. (2010). Children and AIDS: Fifth stocktaking report, 2010. New York, UNICEF.
http://www.unicef.org/aids/files/5thStocktakingKeyFacts_Final_letter(1).pdf
World Health Organization (WHO). (1999). WHO Information Series on School Health. Document six. Preventing
HIV/AIDS/STI and related discrimination: An important responsibility of health-promoting schools. Geneva, WHO.
http://www.who.int/school_youth_health/media/en/90.pdf
Reviewed by Clemens Benedikt and Asha Mohamud (United Nations Population Fund [UNFPA]); and Yong Feng Liu
(UNESCO).
Thematic Indicator 12: Sexual and Reproductive Health
Approximately 1 million girls aged 10 to 14 years and Schools can be a strategic entry point for addressing
16 million girls aged 15 to 19 years give birth every sexual and reproductive health since they reach a large
year, with the majority of these early pregnancies number of the world’s children during a critical
occurring in developing countries (WHO, 2013). Since developmental period. As research has shown,
adolescence is a critical time of development with reproductive health education does not lead to earlier or
striking physical and emotional changes that affect increased sexual activity among young people and can
young people’s health, adolescents need reliable in fact reduce sexual risk behavior. Sexual and
information as they deal with these new experiences reproductive health interventions can be included within
and developments. Around the world, millions of young the FRESH pillars as schools create supportive school
people are sexually active, though not always by their policies that provide an essential framework: skills-
own choice. The resulting too-early sexual relationships based health education that includes age-appropriate
and pregnancies can have profound effects on young content and participatory learning methods; a healthy
people’s health and negatively affect their social physical and psychosocial school environment; and
development, educational pursuits and job opportunities school-based health and nutrition services that provide
(WHO, 2003). adolescent-friendly reproductive health services and
mental health promotion, counseling and social support
(WHO, 2003).
Schools should support decisions concerning
reproduction to be made free from discrimination,
coercion and violence, and discourage early marriages
and gender-based violence (such as rape, coercive sex,
abuse, and exploitation). Schools can also encourage
and support parents and families to communicate with
their children about sexual and reproductive health and
facilitate change in thinking about harmful traditional
practices and gender discrimination.
Sexual and Reproductive Health Indicators Table

Frequency Methods
FRESH PILLARS
1. National policies that prohibit discrimination on basis of gender Every 2 years Policy review
identity, sexual orientation or physical and intellectual disability.
2. National policies that prohibit bullying, sexual harassment and sexual Every 2 years Policy review
violence.
3. National policy mandating inclusion of evidence-based comprehensive Every 2 years Policy review
sexuality education in the school curriculum and linkage to services.
4. Percentage of educational institutions that have rules and guidelines for Every 2 years EMIS annual
staff and students related to physical safety, stigma and discrimination school/college/
and sexual harassment and abuse that have been communicated to institution census
relevant stakeholders. questionnaire
targeting principals
and heads of
educational
institutions.
5. Percentage of schools that always allow pregnant students to attend Every 3 to 5 years Global SHPPS
school.
6. Percentage of schools reporting number of female learners dropping Annually EMIS

out of school due to pregnancy.
1. Percentage of female students who have access to sanitary products Every 2 years School survey
during menstruation.
2. Percentage of schools with separate toilets or latrines for boys to use. Every 3 to 5 years Global SHPPS
3. Percentage of schools with separate toilets or latrines for girls to use. Every 3 to 5 years Global SHPPS

1. Percentage of schools that provided education on sexual and Every 3 to 5 years Global SHPPS
reproductive health.
2. Percentage of students who have received at least 45 minutes of Every 2 years School survey
comprehensive sexuality education per week in the last year.
3. Percentage of students who have talked with a parent(s) or a trusted Every 2 years School survey
adult regarding sexual and reproductive health matters in the last year.
4. Percentage of teachers who received at least 8 hours of training in Annually Training records
evidence-based comprehensive sexuality education. and EMIS
1. Percentage of schools who have access to school-based or school- Annually EMIS
linked sexual and reproductive health counseling and services.
2. Percentage of schools that provide testing, treatment, or referrals for Every 3 to 5 years Global SHPPS
sexually transmitted infections.
3. Percentage of schools that identify or refer students for physical, Every 3 to 5 years Global SHPPS
sexual, or emotional abuse.
OUTCOMES
LEARNING
1. Percentage of students who know how to tell someone they do not Every 3 to 5 years GSHS core-expanded
want to have sexual intercourse with them. questions
2. Percentage of students who know how to tell someone they do not Every 3 to 5 years GSHS core-expanded
want to have sexual intercourse with them unless a condom is used. questions
3. Percentage of learners who disapprove of (have negative attitudes Every 2 years Student survey
towards) rape, incest, coercive sex, sexual harassment, stigma and
discrimination, marriage before age 18, Female Genital Mutilation
(Attitude Index).
BEHAVIORAL
1. Percentage of students who used a condom the last time they had Every 3 to 5 years GSHS
intercourse.
2. Percentage of students who used any other method of birth control, Every 3 to 5 years GSHS
such as withdrawal, rhythm, birth control pills, or any other method to
prevent pregnancy the last time they had intercourse.
IMPACT
1. Percentage of students aged 15 to19 years who unintentionally Every 4 to 5 years Population-based
became pregnant or impregnated someone. surveys (DHS or MICS)

World Health Organization (WHO). (2003). WHO Information Series on School Health. Document eight. Family life,
reproductive health, and population education: Key elements of a health-promoting school. Geneva, WHO.
http://www.who.int/school_youth_health/media/en/family_life.pdf
Additional information:
World Health Organization (WHO). (2013). Sexual and reproductive health. Preventing early pregnancy through
appropriate legal, social and economic measures. Geneva, WHO.
http://www.who.int/reproductivehealth/topics/adolescence/laws/en/index.html
Reviewed by Clemens Benedikt and Asha Mohamud (UNFPA); and Colleen Keilty, Suzanne Field and Elyse Ruest-
Archambault (Right to Play).
Thematic Indicator 13: Substance Abuse
Rationale
Substance abuse indicates the use of psychoactive substance use. Planning of school-based prevention
substances to a harmful or hazardous extent (WHO, interventions should take into account the following
2013a). These substances used by school-age children factors: levels of drug use among individuals and in
include tobacco, alcohol, illicit (illegal or unlawful) drugs, society; risk and protective factors in the given
prescription drugs and over-the-counter medicines. community; gender; ethnicity; culture; language;
The overuse of alcohol causes 2.5 million deaths per developmental-level; ability-level; religion; and sexual
year, and causes 9% of all deaths of young people aged orientation (UNODC, 2004). Specific substances should
15 to 29 years. Globally, an estimated 15.3 million not be discussed before the initiation age. With primary
people have drug use disorders (WHO, 2013b). schoolchildren, the most beneficial approaches focus on
improving classroom management skills of teachers,
It is the primary role of the school to teach skills
and on supporting the growth of social and emotional
that support mental and emotional well-being,
skills of students (UNODC, 2013).
impart knowledge and values in relation to health and
substance abuse, and help students to adopt healthy Effective school policies on substance use mandate that
lifestyles. It is important to recognize that these substances should not be used on school premises or
skills may not be able to change behaviors determined during school functions and activities by both students
by factors beyond the influence of the school and staff. Policies also create transparent and non-
(UNODC, 2004). punitive mechanisms to address incidents of substance
use, including referral and cessation support, to
Strategies transform it into an educational and health promoting
opportunity. Furthermore, altering the school
Educational interventions for the prevention of drug
environment to increase commitment to school, student
abuse are delivered by trained facilitators. In effective
participation, positive social relationships and
prevention programs students are engaged in interactive
discouraging negative behaviors may reduce drug use
activities to give them the opportunity to learn and
and other risky behaviors (UNODC, 2013).
practice a range of personal and social skills. These
programs focus on fostering drug and peer refusal Some responses to drug use may marginalize and
abilities that allow young people to counter social stigmatize students. Detection of drug use with a solely
pressures to use drugs and in general cope with punitive outcome is not a productive strategy unless the
challenging life situations in a healthy way. In addition, health and safety of the school community is being
they provide the opportunity to discuss in an age- compromised. Strictly punitive consequences could
appropriate way the different social norms, attitudes and alienate students at risk from the only place where
positive and negative expectations associated with individuals and activities can support their efforts to
substance use, including the consequences of change (UNODC, 2004).
Substance Abuse Indicators Table

Frequency Methods
FRESH PILLARS
1. National curriculum includes a given number of hours per grade for Every 2 to 3 years Curriculum analysis
evidence and skills-based education on substance use. (refer to the United
Nations Office on Drugs
and Crime (UNODC)
Prevention Standards
for definition of
evidence-based)
2. Percentage of schools that have a written substance abuse policy (or Every 3 to 5 years Global SHPPS
health policy with a strong substance abuse component) prohibiting use
of psychoactive substances, alcohol, and tobacco by students and by
faculty and staff on all school premises and during all school-sponsored
activities.
3. Percentage of schools that have a written policy on how to respond in a Every 3 to 5 years Global SHPPS
non-punitive manner when students are caught using psychoactive
substances, alcohol, or tobacco on school premises or during school-
sponsored activities.
1. Percentage of schools where substance abuse policies are regularly Every 3 to 5 years Global SHPPS
enforced.
2. Percentage of schools where tobacco and alcohol advertising is Every 3 to 5 years Global SHPPS
prohibited on all school premises.

1. Percentage of students that were taught about alcohol or other drug Every 3 to 5 years GSHS
use prevention.
2. Percentage of students who were taught about tobacco use prevention. Every 3 to 5 years GSHS
1. Percentage of school-based clinical/ infirmary staff trained in Every 2 years School and
substance abuse prevention and treatment. teacher survey
2. Percentage of schools where students found possessing or using Every 2 years School and
alcohol, illegal drugs or prescription medicine for non-medical teacher survey
purposes are always mandated for further service and treatment.
3. Percentage of schools where a school or family meeting is always Every 2 years School and
organized for students found possessing or using alcohol, illegal teacher survey
drugs, cigarettes, or prescription medicine for non-medical purposes.
OUTCOMES
LEARNING
1. Percentage of students answering they would accept, if one of their Every 2 years School survey/GSHS
best friends offered a drink of alcohol.
2. Percentage of students who reported they have received substance Every 2 years School survey/GSHS
specific information in schools.
3. Percentage of students answering they have been taught resistance Every 2 years School survey
skills in relation to alcohol.
BEHAVIORAL
1. Percentage of schools where staff members do not smoke Every 2 years School and
during the day or smoke in designated areas. teacher surveys
2. Percentage of schools where students do not smoke on school grounds. Every 2 years School and
teacher surveys
3. Percentage of students who had at least one alcoholic drink during Every 3 to 5 years GSHS
the last 30 days.
4. Percentage of students who have used marijuana during the past 30 days. Every 3 to 5 years GSHS
5. Percentage of students who have used amphetamines or Every 3 to 5 years GSHS

methamphetamines (also use country-specific slang terms) during
their life.
6. Percentage of students who smoked cigarettes during the past 30 days. Every 3 to 5 years GSHS
IMPACT
1. Percentage of students aged 13 to 15 years who have ever tried cannabis. Every 3 to 5 years School survey /GSHS
or Health Behavior in
School-Aged Children
(HBSC).
2. Percentage of students aged 13 to 15 years who have ever been drunk. Every 3 to 5 years School survey /GSHS
or HBSC.
ESPAD. (2012). The European School Survey Project on Alcohol and Other Drugs (ESPAD). ESPAD. www.espad.org
EU-DAP. (n.d.). UNPLUGGED Area: Education material. Prevention curriculum. EU-DAP.
http://www.eudap.net/Unplugged_HomePage.aspx
HBSC. (n.d.). Health Behavior in School-aged Children (HBSC). WHO Collaborative Cross-National Survey. St. Andrews,
Fife, HBSC. http://www.hbsc.org/
Organization of American States. (2005). Time to prevent. CICAD Hemispheric guidelines on school-based prevention.
Washington D.C., Organization of American States. http://cicad.oas.org/Main/Pubs/DR/Guidelines-School-Prev-eng.pdf
UNODC. (2013). International Standards for Drug Use Prevention. Vienna, UNODC.
http://www.unodc.org/unodc/en/prevention/prevention-standards.html
UNODC. (2004). Schools: School-based education for drug abuse prevention. New York, United Nations.
http://www.unodc.org/pdf/youthnet/handbook_school_english.pdf
World Health Organization (WHO). (2013a). Substance abuse. Geneva, WHO.
http://www.who.int/topics/substance_abuse/en/
World Health Organization (WHO). (2013b). Management of substance abuse. Facts and figures.
http://www.who.int/substance_abuse/facts/en/
World Health Organization (WHO). (2013c). Global school-based student health survey (GSHS). Geneva, WHO.
http://www.who.int/chp/gshs/en/ (For substance use-related evaluation the following modules are specifically
recommended: Alcohol Use Module, Drug Use Module, Tobacco Use Module, Mental Health Module, Protective
Factors Module).
World Health Organization (WHO). (n.d.). WHO Global School Health Policies and Practices Surveillance Study (SHPPS):
Draft tools. [unpublished document]. Geneva, WHO.
Reviewed by Giovanna Campello, Hanna Heikkila, and Beth Mattfeld, (UNODC) and Clemens Benedikt and
Asha Mohamud (UNFPA).
Thematic Indicator 14: Violence in Schools
Rationale
Children spend more time in the care of adults in schoolyard fighting, gang violence, and assaults with
preschools and schools than they do anywhere else weapons (United Nations, 2006). A physical attack
outside of their homes. Like parents, the adults who occurs when one or more people hit or strike someone,
oversee, manage and staff these places have a duty to or when one or more people hurt another person with a
provide safe and nurturing environments that support weapon (such as a stick, knife, or gun). It is not a
and promote children’s education and development. physical attack when two students of about the same
They also have a duty to make sure such development strength or power choose to fight each other.
prepares children for life as responsible adults, guided
by values of non-violence, gender equality, non- Strategies
discrimination, tolerance and mutual respect. These are
School-based anti-violence interventions include:
the values that governments embrace when they ratify
interventions that develop better social skills, higher
the Convention on the Rights of the Child and other
self-esteem and a greater sense of personal control over
international human rights conventions (OHCHR, 2013;
their lives, helping students attain higher levels of
United Nations, 2006).
academic achievement; development and
Schools are uniquely placed to break the patterns of implementation of policies (or codes of conduct)
violence by giving children, their parents and governing the conduct and discipline of teachers and
communities the knowledge and skills to communicate, students and building community confidence in schools;
negotiate and resolve conflicts in more constructive good teacher recruitment and training; and involving
ways. The forms of violence found in schools can be parents and communities to monitor schools and
physical, sexual, and emotional, and can occur together. intervene when necessary (United Nations, 2006).
Violence perpetrated by teachers and other school staff School-based anti-violence interventions also include
include corporal punishment and other cruel and dating violence prevention programs, evidence-based
humiliating forms of punishment or treatment, sexual life skills programs, academic enrichment, and whole-
and gender-based violence. Violence perpetrated by school approaches.
children includes bullying, sexual and dating violence,
Violence in Schools Indicators Table

Frequency Methods
FRESH PILLARS
1. Existence of national policy on violence prevention, prohibition of Annually Key informant
corporal punishment and/or bullying in school. interviews
policy/guideline/rule prohibiting fighting and other forms of violence
among students at school.
policy/guideline/rule prohibiting bullying among students at school.
policy/guideline/rule prohibiting physical or sexual abuse of students
by teachers or staff.
policy/guideline/rule prohibiting corporal punishments of students by
teachers or staff.
6. Percentage of schools routinely collecting data on violent incidents Annually School survey
that have occurred on the school property.
1. Extent to which safety and security policy has been implemented in Annually Key informant
schools. interviews

1. Percentage of students exposed to classes in which they were taught Every 2 years School survey
how to avoid physical fights and violence.
2. Percentage of teachers who have been trained how to avoid bullying. Annually School survey
OUTCOMES
LEARNING
BEHAVIORAL
1. [Optional] Percentage of students carrying guns and knives on the Every 3 to 5 years GSHS core
school property during the past 30 days. expanded only
IMPACT
1. Percentage of students who have been in a physical attack during the Every 3 to 5 years GSHS
past 12 months.
2. Percentage of students who were bullied during the past 30 days. Every 3 to 5 years GSHS

Plan International. (2013). Learn without fear. The global campaign to end violence in schools. Woking, Surrey, Plan
International. http://plan-international.org/learnwithoutfear
United Nations. (2006). Violence against children. United Nations Secretary-General’s Study. Geneva: UN.
http://www.unicef.org/violencestudy/reports.html
United Nations Office of the High Commissioner for Human Rights (OHCHR). (2013). Convention on the rights of the
child of 1989. Geneva, OHCHR. http://www.ohchr.org/EN/ProfessionalInterest/Pages/CRC.aspx
World Health Organization (WHO). (2013). Global school-based student health survey (GSHS). Geneva, WHO.
http://www.who.int/chp/gshs/en/
World Health Organization (WHO). (2010a). Violence prevention: the evidence. Series of briefings on violence
prevention. Geneva. WHO.
http://www.who.int/violence_injury_prevention/violence/4th_milestones_meeting/evidence_briefings_all.pdf
World Health Organization (WHO). (2010b). Preventing intimate partner and sexual violence against women: Taking
action and generating evidence. Geneva, WHO.
http://apps.who.int/iris/bitstream/10665/44350/1/9789241564007_eng.pdf
Reviewed by Berit Kieselbach (WHO).
Thematic Indicator 15: Disaster Risk Reduction
Rationale
Emergencies, such as conflict-related, environment- • Safe School Facilities: Including safe site selection,
related or health outbreak-related disasters expose safe access, disaster-resilient design, construction,
school-age children to risks. Health epidemics or maintenance and retrofit, and climate-smart
outbreaks of disease can be caused by emergencies or interventions.
can by themselves cause an emergency. Disasters can
• School Disaster Management: Ongoing school-
have physical, educational, economic, and psychosocial
based assessment and planning for risk reduction
impacts on schools (Petal, 2008). School attendance
and educational continuity; physical and
gives children a sense of security and continuity.
environmental risk mitigation measures, standard
Whether the emergency is a conflict, disaster or
operating procedures for the types of threats faced,
epidemic, children have the same rights to education
and response preparedness (both skills-practiced
and protection as in non-emergency situations.
and improved through drills -and provisions).
Strategies • Risk Reduction Education: Infusion of hazard
awareness and key messages for actionable risk
Schools or learning spaces that meet the Inter-Agency
reduction as well as skills for problem-solving, in
Network for Education in Emergencies minimum
formal school curricula and non-formal education
standards (INEE, 2012) provide protective policies and a
(IFRC, 2012; UNESCO, 2013).
safe and secure learning environment, relevant teaching
and learning opportunities, and basic health, nutrition Disaster risk reduction education through schools
and psychosocial services. These minimum standards should start with teacher training and curriculum
complement the Sphere Project Humanitarian Charter development to support large-scale teaching of disaster
and Minimum Standards in Disaster Response risk reduction. Governments should review the safety
(The Sphere Project, 2004). of schools and develop a comprehensive policy, taking
Comprehensive School Safety aims to both protect all locally relevant hazards into account. Schools can
children and staff from physical harm and to ensure start with teaching about safety and natural hazards
school continuity. It rests on three pillars, as defined (UNISDR, 2006).
by agencies working on disaster risk reduction
(UNICEF et al., 2012):
Disaster Risk Reduction Indicators Table

Frequency Methods
FRESH PILLARS
1. Existence of a national-level comprehensive school disaster Every 2 years Policy review
management plan for child safety and protection and educational
continuity in the face of health, natural and man-made hazards, and
conflict.
2. Existence of national-level guidance for standard operating procedures Every 2 years Policy review
for all known hazards, to protect children from sudden onset disasters
and emergencies and to respond to early warning.
3. Percentage of schools with an ongoing committee responsible for Every 2 years School survey
leading risk assessment, risk reduction and response preparedness
planning.
1. Percentage of schools designed and constructed, reconstructed or Every 2 years School survey
retrofitted to be disaster-resilient.
2. Existence of building codes to ensure disaster-resilient construction of Every 2 years Building code analysis
schools.
3. Percentage of schools and learning spaces sites selected to be safe Every 2 years School records
from known hazards.

1. Life skills-based disaster risk reduction education for building a Every 2 years Curriculum review;
culture of safety and resilience is addressed in the national-level national exams
curricula and in school leaving examinations for primary and reviewed
secondary schools.
2. Life skills-based disaster risk reduction education for building a Every 2 years School survey
culture of safety and resilience is addressed in all school informal
learning activities.
3. Pre-service and in-service training for teachers addressing life skills- Annually Training records
based disaster risk reduction education for building a culture of safety
and resilience.
OUTCOMES
LEARNING
1. Percentage of students who understand basic concepts of disease Annually School survey
outbreaks.
2. Percentage of students who are familiar with key messages for Annually School survey
disaster risk reduction for all hazards, and the specific hazards they face.
3. Percentage of students who are aware of their rights to safety and Annually School survey
protection, and to educational continuity, and their responsibilities in
protecting the environment and reducing risk.
BEHAVIORAL
1. Percentage of students who have reviewed their daily practices and Annually School survey
household disaster plans to become better stewards of risk reduction.
2. Percentage of learners for whom the school has designated Annually School survey
emergency contacts for family reunification.
3. Percentage of students who have participated in school drills to Annually School survey
improve emergency response skills for fire and other known hazards.
IMPACT
1. Number of students attending school/education during or after an Every 2 years School survey
emergency event.
2. Number of students NOT attending school/education during or after an Every 2 years Data from disaster
emergency event. response team

Inter-Agency Network for Education in Emergencies (INEE). (2012). Guidance notes on safer school construction.
UN/ISDR, Geneva. www.preventionweb.net/go/10478
International Federation of Red Cross and Red Crescent Societies (IFRC). (2012). Public education and public
awareness for disaster risk reduction: Key messages. Geneva, IFRC. http://preventionweb.net/go/31061
Petal, M. (2008). Disaster prevention for schools: Guidance for education sector decision-makers. Consultation
version. Geneva, UN/ISDR. http://preventionweb.net/go/7344
The Sphere Project. (2004). Humanitarian charter and minimum standards in disaster response. Geneva, The Sphere
Project. http://ocw.jhsph.edu/courses/refugeehealthcare/PDFs/SphereProjectHandbook.pdf
UNESCO. (2013). Towards a learning culture of safety and resilience: Integrating disaster risk reduction into school
curricula. Kathmandu, UNESCO. http://www.unesco.org/new/en/kathmandu/about-this-office/single-
view/news/towards_a_learning_culture_of_safety_and_resilience_integrating_disaster_risk_reduction_into_school_c
urricula/
UNESCO and UNICEF. (2012). Disaster risk reduction in school curricula: Case studies from thirty countries. Geneva,
UNICEF & UNESCO. http://preventionweb.net/go/26470
UNICEF, UNESCO, Save the Children, Plan International, World Vision, and ADPC. (2012). Comprehensive school safety.
Working towards a global framework for climate-smart disaster risk reduction, bridging development and
humanitarian action in the education sector. http://preventionweb.net/go/31059
UNISDR (United Nations International Strategy for Disaster Reduction). (2006). Disaster risk reduction begins at school:
2006-2007 world disaster reduction campaign. Geneva, UNISDR. http://preventionweb.net/go/3914
Reviewed by Marla Petal (Risk RED).
For further information, please contact the
FRESH partner organizations through
info-iatt@unesco.org
www.unesco.org/new/health-education

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Monitoring and

Abbreviations and Acronyms 3

AIDS Acquired immune deficiency syndrome

Thematic Indicators Thematic Areas (Health Topics)

Indicators Data Collection Data Collection

SAFE LEARNING ENVIRONMENT

ALTERNATIVE INDICATORS (from global surveys)

SCHOOL-BASED HEALTH AND NUTRITION SERVICES

Every 2 years for a

Indicators Data Collection Data Collection

SAFE LEARNING ENVIRONMENT

SKILLS-BASED HEALTH EDUCATION

Sources and Further Information

Rationale (Save the Children, in press). Micronutrient

Indicators Data Collection Data Collection

SKILLS-BASED HEALTH EDUCATION

SCHOOL-BASED HEALTH AND NUTRITION SERVICES

5. Improved micronutrient intake in school. Every 2 years Student survey

3. Prevalence of micronutrient deficiencies (e.g. anemia). Every 2 years Student survey

Sources and Further Information

Physical Activity Indicators Table

Indicators Data Collection Data Collection

SKILLS-BASED HEALTH EDUCATION

Sources and Further Information

Indicators Data Collection Data Collection

SAFE LEARNING ENVIRONMENT

SKILLS-BASED HEALTH EDUCATION

SCHOOL-BASED HEALTH AND NUTRITION SERVICES

Sources and Further Information

Indicators Data Collection Data Collection

SKILLS-BASED HEALTH EDUCATION

SCHOOL-BASED HEALTH AND NUTRITION SERVICES

Sources and Further Information

Indicators Data Collection Data Collection

SKILLS-BASED HEALTH EDUCATION

SCHOOL-BASED HEALTH AND NUTRITION SERVICES

Sources and Further Information

Reviewed by Peter Ackland (International Agency for the Prevention of Blindness).

Ear and Hearing Indicators Table

Indicators Data Collection Data Collection

SAFE LEARNING ENVIRONMENT

SKILLS-BASED HEALTH EDUCATION

1. Percentage of children with hearing loss. Every 2 years School records /

Sources and Further Information

Reviewed by Shelly Chadha (WHO).

Indicators Data Collection Data Collection

SKILLS-BASED HEALTH EDUCATION

SCHOOL-BASED HEALTH AND NUTRITION SERVICES

ALTERNATIVE INDICATOR (from global surveys)

1. Percentage of school-age children/ adolescents who received the Annually Administrative

1. Age-specific (e.g. school-age) incidence rate of measles and Annually Disease

Reviewed by Tracey Goodman and Leanne Riley (WHO).

Injury Prevention Indicators Table

Indicators Data Collection Data Collection

SAFE LEARNING ENVIRONMENT

SKILLS-BASED HEALTH EDUCATION

SCHOOL-BASED HEALTH AND NUTRITION SERVICES

Reviewed by Kidist Bartolomeos and Leanne Riley (WHO).

Indicators Data Collection Data Collection

SAFE LEARNING ENVIRONMENT

SKILLS-BASED HEALTH EDUCATION

SCHOOL-BASED HEALTH AND NUTRITION SERVICES

Sources and Further Information